Radiation Oncology/Head & Neck/Sinonasal/Nasal cavity

Epidemiology

• M>F 2:1
• 3% of upper respiratory tract cancers

Anatomy

• For the purpose of staging, is divided into four subsites: septum, floor, lateral wall, and vestible.

• Nasal vestibule is the anterior nasal cavity extending from the nostrils to the internal nasal valve.

• Lateral wall of nasal cavity includes the superior, medial and inferior turbinates, the nasolacrimal duct, and the osteomeatus.

• 5-12% incidence of nodal mets at diagnosis.

• Draining lymphatics of nasal vestibule include Level I, facial and preauricular.

Staging: see Staging

Histology

Nasal Cavity

• SCC 50%
• Esthesioneuroblastoma 13%.
• Melanoma 10-15%

Nasal Vestibule

• SCC 80%

Treatment of Carcinoma of Nasal Vestibule

• Tumors of the nasal vestibule are typically considered separate from nasal cavity tumors, because they are essentially skin cancers and as such have a different natural history
• Definitive radiation therapy preferred over primary surgical approach for T1-2N0 SCC of nasal vestibule because of good local control of xrt and major cosmetic sequellae of surgery.

Definitive Radiation for Nasal Vestibule

• The Netherlands, 2004 PMID 15275715 -- Langendijk JA et al. "Radiotherapy of squamous cell carcinoma of the nasal vestibule." Int J Radiat Oncol Biol Phys 2004 Aug 1;59(5):1319-25.
  • 56 pts w/ Wang Classification T1 and T2 tumors tx'd w/ external beam xrt +/- endocavitary brachytherapy boost.
  • Local control rate at 2 yrs was 80%. 12% developed nodal metastases.

• Gainesville, 1999 (1970-1995) PMID 10402517 -- Mendenhall WM et al. "Squamous cell carcinoma of the nasal vestibule." Head Neck. 1999 Aug;21(5):385-93.
  • 56 pts tx'd w/ xrt alone and 4 w/ xrt followed by surg
  • 5yr local control 94%, T4 71%
  • 5yr CSS 94%, T4 86%

• Denmark, 1984 PMID 6331090 -- Johansen LV et al. "Squamous cell carcinoma of the nasal vestibule. Treatment results." Acta Radiol Oncol. 1984;23(2-3):189-92.
  • 66 pts w/ SCC of nasal vestibule, mostly tx'd w/ xrt alone.
  • Cure rate for Wang's T1 (81%) and Wang's T2 (52%). 12/22 local recuurence salvaged successfully w/ surgery.
  • Local recurrence w/ T3 was 88%

Prognostic Factors for Nasal Vestibule

• Princess Margaret, 2007 (1979-2000) PMID 17298305 -- Jeannon J-P et al. "Prognostic indicators in carcinoma of the nasal vestibule." Clin Otolaryngol. 2007 Feb;32(1):19-23.
  • Largest published series of SCC of nasal vestibule.
  • 84 pts w/ SCC of nasal vestibule w/ 77% managed w/ primary xrt
  • 5yr OS 58%, 5yr DFS 52%
  • Wang classification only prognostic indicator significant on multi-variate analysis.

• MGH, 1976 PMID 820421 -- Wang CC. "Treatment of carcinoma of the nasal vestibule by irradiation." Cancer. 1976 Jul;38(1):100-6.
  • 36 pts w/ SCC of nasal vestibule
  • 3yr NED rates were 83% for Wang's T1, 71% for Wang's T2, and 50% for Wang's T3
  • Pts w/ bone destruction best tx'd w/ primary surgical approach +/- xrt.

Treatment of Carcinoma of Nasal Cavity

• Definitive radiation therapy for nasal cavity is preferred over surgery, and may include a brachytherapy boost.
• SEER Database analysis, 2002 PMID 12220216 -- Bhattacharyya N. "Cancer of the nasal cavity: survival and factors influencing prognosis." Arch Otolaryngol Head Neck Surg 2002 Sep;128(9):1079-83.
  • 981 pts, 97% non-metastatic, SCC 50%, esthesioneuroblastoma 13%, xrt delivered in 50% cases.
  • Overall 5 yr survival 57%
• MD Anderson, 1992 (1969-1985) PMID 1410570 -- Ang KK. "Carcinomas of the nasal cavity." Radiother Oncol. 1992 Jul;24(3):163-8.
  • 45 pts w/ carcinoma of nasal cavity tx'd curatively (18 xrt alone, 27 surg + xrt)
  • All pts w/ dz originating from septum controlled. 9/31 w/ dz from floor or lateral wall of nasal cavity died of dz
  • OS at 5 yrs 75%, at 10 yrs 60%
  • 4 pts had blindness (2 from xrt, 2 from exenteration).
• Mallinkrodt, 1988 (1969-84) PMID 2846481 -- Hawkins RB. "Carcinoma of the nasal cavity--results of primary and adjuvant radiotherapy." Int J Radiat Oncol Biol Phys. 1988 Nov;15(5):1129-33.
  • 62 pts w/ CA of nasal cavity tx'd w/ either definitive xrt or surg + xrt. No elective nodal tx given.
  • 52% 5yr OS, 32% 10 yr OS
  • 49% tx'd w/ xrt alone controlled, 82% tx'd w/ surg + xrt controlled
  • 19% failed in nodes in pts who were initially N0.